Bilateral Transtibial Geriatric Amputee: Amputee Case Study

Title

Bilateral Transtibial Geriatric Amputee: Amputee Case Study

Abstract

This is a case study about a geriatric client that had bilateral transtibial amputations as a result of complications post cardiovascular surgery. Despite his age, amputations and co-morbidities he had a very positive outcome.

Key Words

geriatric, bilateral, transtibial

Client Characteristics

Mr Smith is a 80 year old male with bilateral trans-tibial amputations. He is retired and lives with his wife in a single-level home. He has four steps into his home with bilateral handrails. He volunteered as a pastor at the local hospital and long-term care facility prior to his amputations. He was very active and walked daily, with no gait aid.
 He had a myocardial infarction, followed by a cardiac catherization with a metal stent and repair of a ventrical septal rupture. His post-op course included ventilation, a tracheotomy and acute ischemic complications that lead to bilateral foot necrosis and subsequent bilateral trans tibial amputations.
His co-morbidities include coronary artery disease, congestive heart failure, ventricular defecit and bladder cancer.
He was followed initially in acute care for pre-prosthetic training. This included use of stump shrinkers, positioning, an amputee board for his wheelchair, transfers from bed- wheelchair with a sliding board, an extensive exercise program and education. Following this he was sent to a rehabilitation center for prosthetic fitting and gait training. While in the rehabilitation center he achieved all his goals on the FIM and could ascend/ descend with a 4-point cane and rail. He was fitted with bilateral patellar bearing socket prostheses. His Berg Balance score was 22/ 56 upon discharge from the rehabilitation center. He was referred to outpatient physiotherapy service for continuing care.

Examination Findings

On assessment Mr. Smith reported no pain, phantom pain or issues with his stumps or protheses. He relayed that he was being followed by a prosthetist and physiatrist. His past medical history was as above. He was independent in most of his activities of daily living, requiring minimal assistance from his wife to bathe. He transferred independently and was ambulating around the house for short distances with a two-wheeled walker, using a wheelchair for longer distances.

He had a positive attitude and supportive spouse. He was unable to return to gardening and missed his ministry work. His goal was to be able to walk without a cane and return to his work as a volunteer pastor. His physical assessment revealed well-healed stumps with no skin issues.

Range of motion was - 15 degrees right knee extension, - 10 degrees left knee extension, 15 degrees right hip extension and 5 degrees left hip extension. All other movements were within functional limits. Strength testing revealed bilateral grade 5 hip abduction and flexion, bilateral grade 4 + hip extension and knee extension in available range.

He ambulated with a two-wheeled walker with a flexed posture and had poor foot clearance bilaterally. His Berg Balance score was 23/56. His vital signs were monitored and at rest his blood pressure was 113/63 and his heart rate was 82, no shortness of breath was detected. After 15 minutes on the NUSTEP his blood pressure was 104/73and his heart rate was 77.

Clinical Hypothesis

Mr. Smith's main issues; were decreased conditioning complicated by cardiovascular disease and the increased energy cost of ambulating with bilateral trans tibial prostheses, decreased balance and the potential for falls, and poor gait pattern. His post op complications from his original vascular surgery and the resulting long pre prosthetic preparation were added to his deconditioned state.

Intervention

Mr. Smith attended physiotherapy twice a week for several months. During his sessions his blood pressure and heart rate were monitored. He was very motivated and compliant with his program but often pushed the boundaries and had to be reminded of fall risks.

His outpatient program included an exercise program of strengthening for hip and knee extensors, prone lying and review of positioning, aerobic training using the NUSTEP, weight shifting and unsupported standing in the parallel bars progressing to eyes closed balance and balance on a foam cushion - while monitoring the time that he could sustain each, gait training starting with walking unsupported with a gait belt and minimal assistance in the parallel bars and progressing to a 4 point cane with a gait belt and assistance, walking with a single cane with a wide based tip and finally to walking 120 meters with no gait aid unsupported in the physiotherapy department.

Outcome

Upon discharge from active physiotherapy intervention Mr. Smith had achieved his goals. His Berg balance score had improved to 41/56 and his active ROM and strength was functional. He once again was ambulatory in his community, walking independently two kilometers with a single point cane. He was walking independently without aid inside his home and was able to do all of his activities of daily living.

He decided not to drive again, but did not feel this was a limitation as his wife could drive and he had the support of several friends to provide transportation if needed. He had returned to gardening and his ministry at the hospital and long term care facility, which he greatly enjoyed. He continued to have no pain or phantom pain and was having no skin or prosthetic issues.

He had a follow-up appointment with the physiatrist for continuing care. He and his wife were very pleased with his outcomes and attributed his successful rehabilitation to a positive attitude and faith.

Discussion

Mr Smith had an excellent outcome despite the many challenges he faced. Having bilateral trans tibial amputations is extremely energy consuming[1] which is a challenge in itself, however Mr. Smith's age and co-morbidities added more concern. His program had to include aerobic conditioning with close monitoring of his cardiovascular status[2] and progressing his program being mindful of his risk of falls. Balance training was an integral part of his rehabilitation, and safety was of the upmost concern. Use of the parallel bars was essential[3].

The use of the Nustep was also very useful as seated aerobic work posed less risk. While the Berg Balance Scale provided useful information, the six minute walk or timed up and go test may also have be utilized. Mr. Smith was fortunate that he had good healing and experienced no pain or phantom pain during his rehabilitation process. His social support, positive attitude and motivation contributed to his ability to cope with this potentially devastating, but surely life altering event. He taught our rehabilitation team to always treat the individual and objective findings and not pre-judge patients on the basis of age, co-morbidities or amputation.

References

  1. Engstrom, Barbara , Van de Ven, Catherine. Therapy for Amputees
  2. Gailey, Robert S, Gailey, Ann M. Balance, Agility, Co-ordination and Endurance
  3. Prosthetic Gait Analysis for Physiotherapists